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Topic: help! Value Options/ NYSHIP (Read 582 times)

I bill for a NY LMHC. She is INN with Value Options for MVP commercial only. She is OON for NYSHIP via Value Options. She could not be INN for NYSHIP/ VO even if she wanted to be, as they don't credential LMHCs.

She has been seeing a few NYSHIP people for years. They pay her full fee upfront and we submit the claim as a courtesy not accepting assignment. NYSHIP always pays the patients directly. It's been working great for years.

In August, when she re-credentialed with VO, someone over there must have accidentally checked the "NYSHIP" box. She got a letter that she was "credentialed in error" with NYSHIP and would be "disenrolled Oct 29."

Now her claims for Aug and Sept (and probably Oct) are being processed in network and at the NYSHIP/VO dismal fees ranging from $38- $67. Her patients already paid her normal fees upfront of $110- $150. They've all met their OON deductibles and are expecting their 80% reimbursement checks.

We have called the credentialing dept NUMEROUS times and keep being told we need to wait for someone from the "NY Team" to call us back as they are very backed up.

The LMHC never agreed to a NYSHIP contract and never agreed to their fee schedule. Besides appealing the claims to the claims dept (and we all know the claims dept and the credentialing dept have no idea what the other do), what steps/ recourse can we take?

this is a ridiculous situation, and no one at VO will listen to our point of view and someone (either the provider or the patients) are going to lose a lot of money

YOU have NO contract, NO previous contract, an error was made on THEIR part. That being said, right now you are OON. PERIOD. You have every legal right to bill patient's for balances.

What we did in this instance was tell the patient (even though they were told we were non par at the beginning) that they may get EOB showing no balance due. We then attached that letter given to us from Magellan saying we were credentialed in error (same as you got) and sent patient a bill. We continued, in the meantime, to follow-up with Magellan making sure they fixed it on their end. They did, it took about three months too which upset some patient's but again, we told the patients up-front we were NON par. We also did not show up in any of their par provider books or listings (thank goodness).